<div class="modal-dialog modal-lg ajax-edit-addr-modal">
    <div class="modal-content">

        <!-- header modal -->
        <div class="modal-header">
            <button type="button" class="close" data-dismiss="modal" aria-label="Close"><span
                    aria-hidden="true">&times;</span></button>
            <h4 class="modal-title " id="myLargeModalLabel">编辑收货人信息</h4>
        </div>

        <!-- body modal -->
        <div class="modal-body">
            <form method="post" class="edit-addr">
                <fieldset>
                    <!-- required [php action request] -->
                    <div class="row">
                        <div class="form-group" id="areas">
                            <div class="col-md-3 col-sm-12">
                                <label>所在地区（省份/直辖市） *</label>
                                <select class="form-control pointer " id="province1" name="province" required>
                                    <option value="">--- 省份/直辖市 ---</option>
                                    {% for val in province %}
                                    <option value="{{val.id}}" {% if info.province== val.id %} selected {% endif%}>
                                        {{val.name}}
                                    </option>
                                    {% endfor %}
                                </select>
                            </div>
                            <div class="col-md-3 col-sm-12">
                                <label>（市） *</label>
                                <select class="form-control pointer " id="city1" name="city" required>
                                    {% for val in city %}
                                    <option value="{{val.id}}" {% if info.city== val.id %} selected {% endif%}>
                                        {{val.name}}
                                    </option>
                                    {% endfor %}
                                </select>
                            </div>
                            <div class="col-md-3 col-sm-12">
                                <label>（县/区） *</label>
                                <select class="form-control pointer " id="county1" name="county" required>
                                    {% for val in county %}
                                    <option value="{{val.id}}" {% if info.county== val.id %} selected {% endif%}>
                                        {{val.name}}
                                    </option>
                                    {% endfor %}
                                </select>
                            </div>
                        </div>
                    </div>
                    <div class="row">
                        <div class="form-group">
                            <div class="col-md-12 col-sm-12">
                                <label>街道地址 *</label>
                                <textarea class="form-control required" name="addr" required>{{info.addr}}</textarea>
                            </div>
                        </div>
                    </div>
                    <div class="row">
                        <div class="form-group">
                            <div class="col-md-6 col-sm-6">
                                <label>邮政编码 *</label>
                                <input type="text" class="form-control required" value="{{info.zip}}" name="zip"
                                       required>
                            </div>
                            <div class="col-md-6 col-sm-6">
                                <label>手机号码 *</label>
                                <input type="text" class="form-control required" value="{{info.mobile}}" name="mobile"
                                       required>
                            </div>
                        </div>
                    </div>

                    <div class="row">
                        <div class="form-group">
                            <div class="col-md-6 col-sm-6">
                                <label>收货人姓名 *</label>
                                <input type="text" class="form-control required" value="{{info.accept_name}}"
                                       name="accept_name" required>
                            </div>
                            <div class="col-md-6 col-sm-6">
                                <label>电话号码 </label>
                                <input type="text" class="form-control " value="{{info.phone}}" name="phone">
                            </div>
                        </div>
                    </div>


                    <div class="row">
                        <div class="form-group">
                            <div class="col-md-12 col-sm-12">
                                <label>
                                    设为默认地址

                                </label>
                                <!-- checkbox -->
                                <label class="checkbox">
                                    <input type="checkbox" value="1" name="is_default" {% if info.is_default==
                                           1%}checked{%endif%}>
                                    <i></i> 设置为默认收货地址
                                </label>
                            </div>
                        </div>
                    </div>

                </fieldset>
                <div class="row">
                    <div class="col-md-12">
                        <input type="hidden" name="id" value="{{info.id}}">
                        <input type="hidden" name="type" value="{{type}}">
                        <button class="btn btn-3d btn-teal btn-lg btn-block margin-top-30" type="submit">
                            编辑收货人地址
                        </button>
                    </div>
                </div>

            </form>
        </div>

    </div>
</div>
